Last week’s closing of St. Andrews Emergency Department and swing bed unit made visible by the symbolic sign change seemed like the final chapter in a long, painful drama for this community.

But the Boothbay Region Health and Wellness Foundation is still seeking a sequel. Like late-night party goers who refuse to notice their hostess loading the dishwasher, Foundation stalwarts Patty Seybold, Jane Good and Margaret Jones Perritt aren’t going anywhere. “We have never stepped down,” Good said, “Why would we now?”

The Foundation is currently engaged with state and federal agencies that have granted only temporary approval for the healthcare changes made here on October 1. They are hoping that each agency will take a harder look at their decisions before finalizing them.

What’s at stake?

The first temporary approval affects Medicare reimbursement. On June 27, the Center for Medicare Services granted Lincoln County Healthcare preliminary approval to relocate St. Andrews Hospital to the Miles Memorial Hospital campus and to merge the two hospitals under St. Andrews’ critical access designation, with its higher Medicare reimbursement structure.

Medicare indicated that final approval will be provided only after a full survey is completed after relocation.

To meet Medicare’s relocation criteria, the relocated hospital, LincolnHealth, must serve at least 75 percent of the same service area, provide at least 75 percent of the same services and be staffed by 75 percent of the same staff as the original hospital. LCH has provided data to support its contention that LincolnHealth will meet the criteria; the Foundation has presented arguments that the new merged hospital will not.

In an email, Center for Medicare Services Public Affairs Specialist Courtney Porter Jenkins wrote that the Foundation’s comments regarding LincolnHealth’s ability to meet the criteria will be considered in Medicare’s decision making process. If Medicare ultimately determines that LincolnHealth cannot meet the relocation criteria, critical access status would be revoked and LincolnHealth would have the opportunity to revert to hospital status ( a lower reimbursement structure), Jenkins wrote.

In an October 1 letter to Maine Department of Health and Human Services (DHHS), LCH CEO Jim Donovan reported that the LincolnHealth hospital merger with critical access reimbursement will reduce operating costs by $6.3 million and result in $5.2 million in increased Medicare reimbursement, $4.6 million of which will be used for price reductions. “We’re keeping money in Lincoln County,” Donovan said in an interview, “It’s turned out to be incredibly important to us.”

Foundation President Patty Seybold said in contesting Medicare approval her group is more concerned about the loss of hospital beds (critical access hospitals cannot exceed 25 beds) than dollars. “Bill Caron (MaineHealth CEO) would say it (denial by Medicare) will accelerate the closure of Miles,” Seybold said. “I don’t think the fact we’re standing up for our rights and our beds will cause the demise of Miles any sooner.”

The second issue revolves around state hospital licensing and the Certificate of Need (CON) process. In letters to DHHS, MaineHealth and LCH have stated that creation of LincolnHealth does not require a CON because it “does not involve a transfer of ownership, acquisition of control, capital expenditure, additional operating expense or introduction of a new service” and have produced reams of paper to support that assertion.

Attorney Julius Ciembroniewicz, on behalf of the Foundation, argues that the merger is a transfer of ownership of Miles Memorial Hospital and thus, requires CON review. In a letter to DHHS, Ciembroniewicz wrote, “a corporate merger of two health care entities that results in a transfer of ownership ... requires a CON. MaineHealth cannot be permitted to side-step the legislatively mandated process.”

To date DHHS has not determined whether the CON statute applies in this case. On September 30, one day before the local healthcare changes were instituted, DHHS granted a conditional, six month hospital license to LincolnHealth.

Seybold said her group is most concerned that the public process, including public hearings, is being subverted. “We know it would pass (CON review),” Seybold said, “but the key is we have all been denied the public process.” Seybold also said such a decision by DHHS has ramifications for other hospitals and future mergers throughout the state.

Donovan wrote in an email that he is confident that the CON question will be satisfactorily resolved in LCH’s favor. “Bottom line, this is a restructuring of two subsidiaries (Miles Memorial Hospital and St. Andrews Hospital) of a common parent (LCH),” Donovan wrote.

Good said she has drafted letters to the governor, attorney general and DHHS commissioner seeking a greater level of scrutiny over this decision. “My issue is nobody is overseeing anybody,” Good said. “We need somebody to get a handle on this.”